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AUDIO - HSP #139 - PK Clark
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VIDEO - HSP #139 - PK Clark
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PK Clark places 1500 implants a year. His implants are placed according to three things: Location, Angulation, and Depth. Listen as he explains.
PK is a practicing dentist, lecturer, and surgical mentor. He is passionate about patient-centered care and devoted his professional life to his patients and advance dental procedures. He is often characterized as down-to-earth, thoughtful, passionate and ambitious. PK and his wife, Cheryl, are the proud parents of six children.
http://whitecapinstitute.com/
pk@whitecapinstitute.com
please always CC-bobbi@whitecapinstitute.com
Howard: It is a huge honor today to be podcast interviewing a dental implant legend PK Clark and my little brother is Paul Kenyan, so his nickname was PK too when he was a little kid, but you are actually, I thought I was crazy having 4 kids. You actually had 6 so you are actually 50% more crazy than I am.
PK Clark: Pretty much I think so.
Howard: What are the ages of your kids? From what range, mine are 20 to 26, 23 to 24, 26.
PK Clark: Mine are 22 through 34.
Howard: Okay.
PK Clark: My oldest son is just finishing an oral surgery dual degree at UCSF. We're very proud of him. One of my other sons is a dentist that has joined me at Whitecap Institute. Then I have another son that runs a business called a Social Dental that is doing very well.
Howard: What does Social Dental do?
PK Clark: Social Dental optimizes search engines for dentists. They connect doctors to their patients via all the social networks out there.
Howard: Well let's help Junior out. You tell him to schedule a podcast for me and he could made his pitch to 7,000 people.
PK Clark: I will do that. He would love that.
Howard: Oh yeah and I only do podcast. That's only I would do. I practiced dentistry several days a week and SEO is what it is at. I mean I'm so old. I graduated in ‘87. You graduated in ‘89 right?
PK Clark: That's correct.
Howard: The big thing then was to do or not to do the Yellow Pages and now I know that Yellow Pages are dead and then it went to the personal computer. Now it's the smartphone and now I notice that Google is penalizing your dental website if it's not mobile friendly. If you are on a smartphone and you search for a dentist and the guy across the street has a mobile-friendly website and you don't, you're not going to show up first.
PK Clark: Absolutely.
Howard: Every dentist wants new patients because that's what we went to school for. Fix up people. I have to admit after twenty years, I kind of get tired of the DO and the MO or the single unit crown. My true love is the emergency room. I love two things and that's why I call myself Today's Dental. I love just having someone come in and you don't know what you’ve got and you’ve got to diagnose it and put out the fire and you feel like Batman or Superman when you're done. They came in hurting and they leave all fixed up. It is just the greatest feeling in the world but I’m glad I have you on because I wrote a monthly column every month since 1994.
This month's column was absolutely the most controversial. There's people on there saying they will never listen to Dentaltown again or the army or whatever that and the subject was let me just frame the kind of setup. Basically in the United States with 150,000 dentists, 96% of crowns are done one a time and it's the same with implants. Whenever you go to continue education, it's always these full mouth rehabs. These Mercedes-Benz, Porsches all the stuff like that and then this poor dentist goes back and 96 times our of 100, its one tooth and it's the same with implants. Every time anybody talks about implants, it's always you know all on 4, this big $50,000 deal and all I said was do you really have to have a surgical guide to place the most single common implant, which is replacing a first molar.
You got a tooth in front, you got a tooth behind. You got buccal wall lingual bone. I mean do you really have to have $150, 000 CBCT and a surgical guide to do this, because I can find you dentists who have placed thousands of implants who have never used a surgical guide. I can show you oral surgeons like Jay Resnick in Los Angeles, who is an oral surgeon who used a surgical guide a 100.0% of the time. My job is to make you think. My job isn't the world according to Howdy. I didn’t call it Howardtown.com. Its Dentaltown.com but as a dental journalist I know I hear both sides of the story, so I like to frame Howard speech columns to take your mind out for a five mile run. A lot of them say they don’t want to be challenged.
They don't want anybody to say anything they don't agree with. My first question to you is that just that question. I understand having access to a CBCT to get your anatomy and all that stuff, but do you need a surgical guide to place a single implant replacing a first molar every single time?
PK Clark: Howard I've taught 3500 doctors in the last 12 years how to do implants. At the end of the day when you’ve got adjacent teeth, when you have a lot of bone and good biotype tissue and you got an opposing arch. That's the thing that no one ever mentions. You got an adjacent tooth on either side of your question that you're asking me but you've also got a lower arch. When that patient bites their teeth down you’ve got absolutely everything necessary to put that implant precisely where it needs to go. What’s good for the tooth is not good for the implants. That's an interesting thought.
Howard: I've never even heard that.
PK Clark: This is a PK, this is a PKism; what's good for the tooth in the anterior esthetic zone is not for the implant because of the proprioceptive component to the tooth allows it to be buckled to a potato chip or lingualized to a potato chip of bone, but be the implant fixture which is going to be ankylosed to the bone cannot be in the same position as the tooth because it doesn't have proprioceptive protection. Specific to your question Howard, the answer is without question in my opinion and I do 1500 implants a year. I do a lot of implants you got all the right things right there. You got adjacent teeth. You’ve got to look at the biotype, you've got a good look at the bone.
You’ve got adjacent or the opposing arch you can bite down to and see that the implant is placed according to three things. The three things that you have to think about when you're placing an implant is very simple. Three things; L location where does that implant fit, mesiodistal, buccolingual. Then the second component to the equation is the angulation and that is absolutely dependent upon the opposing arch not necessarily the adjacent teeth. The opposing arch because you want to mitigate deleterious forces that are controlled or propagated if you will by the lower arch. L is location; A is angulation and D is depth. Where do you want the coronal component or the top of the implant body to be relative to the CEJ and why?
These are things so when you get L and you get A and you get D dial because of the adjacent teeth that are present in the body and you use the lower arch to see where the lower component of that occlusion fits, you got a home run. You’ve got a great deal and you're going to have a very happy patient, but you have to know that at the end of the day the goal is stable tissue and stable bone for a long-term preservation of pappillas under an implant. We say all the time to our patient's dozens of times a day they're just like teeth. They’re just like teeth. Yes they might be in dialogue to a patient just like teeth but an implant is far from a tooth because it doesn't have proprioceptive protection. It doesn't have the PDL.
it doesn't have physiologic movement and therefore the clinician’s got to be very, very wise in protecting that non-proprioceptive fixture from deleterious vector forces that will go in a direction that are inconsistent with the long axis of the implant for long-term stability. I started doing implants in 1988 so I've been doing them for a long time and I've seen the good and the bad and the ugly and I participated in at all. I'm very, very happy to say that implants are a wonderful thing for our patients. It's all about the patient and one of the PKisms I would tell you is that when teeth go away bone goes away. Simple as that. When teeth away go bone goes away and the sole purpose of the periodontium or the alveolus is to preserve the tooth.
When the tooth goes away we as clinicians have to be very savvy, very clever on how to preserve that periodontium and the alveolus. Yeah I agree 90% of the teeth that are replaced by implants are done one tooth at a time. Not the sexy exotic full mouth cases that everybody likes to do, but at the end of the day it's about that one patient that's missing the one tooth in the one position that is just debilitating them emotionally. We have the great privilege of restoring that to look like a tooth but function like a fixture without a periodontal ligament fiber. Occlusion is very, very vital to the success of implantology, but I may have been added to your controversy of a month ago. I didn’t know about the controversy but honestly if someone tells you got to place every implant with a surgical guide, I would say I'm not sure about that.
If they said you can place every implant without one, I'm not sure about that. I think you have to look at the case individually, and at the end of the day be satisfied you did all the preparation necessary to give a patient a tooth that's going to last a long time, look great, function as it should and do it in a way that's without pain and suffering.
Howard: Pk just in case someone is living under a rock as there's a lot of kids in dental school or just graduated or other continents listening to this, you made a comment that you’ve educated 3500 dentists. Tell our listeners about the Whitecap Institute and are you teaching the 90% how to replace that single main teeth or is it more exotic training. Furthermore how did you get into this? How did you get into teaching dental implants?
PK Clark: I'm just a dentist and I love my patients and I've been fortunate enough to get … I was just at the right place Howard at the right time in dental school where I did my first dental implants in dental school. I went to my dean and I said “Listen I want to do dental implants” and he said “PK that's going to be impossible.” I said “I hate that word.” He said “Listen it would take the perfect patient, the perfect mentor that isn’t faculty full time. It would take that faculty member to bring in equipment and a dental assistant.” He went on and on and on. I made a mental note of everything my dean told me it would require. Two weeks later I went to my dean and I said “Listen I have the perfect situation. This impossible situation has become possible because of the punch list you gave me.”
He wasn't thrilled to hear that as you might imagine so he said “I want you to promise me PK you will not tell anybody while you're in dental school because the powers that be, all of the political stuff in dental school is going to make this a big big issue.” I said consider it done. I did my first dental implants in 1988 in the basement of OHSU in Oregon with Dr. John Wagner, a wonderful human that has passed on. He taught me how to do these implants, so I started doing them year after year after year so at about 12, 15 years of doing implants my friends would come to me and say “Could you help me?” This was a personal epiphany of thought or a wonderful thing that happened to me. I packaged up all my stuff from my office to help my friends. I took an afternoon off and when I helped my friends do what I had been doing very comfortably for many years, I was blown away. I was satisfied and I was smiling from ear to ear.
I was as happy as they were and at that moment I thought is it possible that I could be a pertinent relevant teacher because I didn't think of myself as special. I went home and I talked to my wife about it. I said I had the crazy thing happen today. I helped my friend do a dental implant in Portland Oregon and all of the sudden, all I can think about is helping others help their patients. I caught on a white board and I put everything I loved about CE on one side. The pro of CE. I put everything I hated about CE on the other side. As you might imagine, the negative of CE far outweighed the positive, and one of the things that really bothered me is the people that were teaching were corporately puppeted.
They are all endorsed by corporate America for making money money money. no one was talking about patient-centered care. No one was talking about doctor patient relationship. No one was talking about the stuff that makes me happy at the end of the day. I decided to run a course. One course led to another. Hundreds of courses later I have 3500 doctors that I consider all but about seven my friends. Some of the seven that showed up were just not like minded. They didn't care for their patients. They were looking for a magic bullet that they can learn everything in a weekend and that's just not Whitecap Institute. Whitecap Institute I started because of a love for patients and a desire if you will to be an example to doctors old and young that we need to remember why we're doing this.
We're doing it because of the patients and we exist because of them. We should serve our patients and when we had that doctor patient relationship in mind, we must epitomize clinical care. When a tooth goes away, bone goes away and to optimally help our patients we need to replace that missing tooth with an implant fixture properly done, properly aligned, proper location, angulation, and depth and be very versed in occlusive forces. Whitecap I only teach about a 150 new doctors a year. I mentor them after they learn how to do it by protocol driven implantology. I hold their hand. I emotionally embrace them. I adopt them and I am having a blast. This is so fun and I have doctors that are unbelievably good clinicians doing really, really good outcomes with their implant solutions and I'm very proud of them.
I'm proud of us as a profession meeting the patient's needs. I had an opportunity last week to have an oral surgeon come down from Idaho to be mentored. I thought what a great opportunity to cross-pollinate his wonderful medical hospital based training with my tire meets the road pragmatic training, and I think we need to do more of that. We need to make our patients number one and a little less territorial bullying and be nice about it. I'll tell you why dental implants should be done by general dentists when they are capable of doing it and when they're not, refer it. Refer it as fast as you can to a capable clinician whoever that might be is because dental implantology if you really think about it Howard is a prosthetic discipline with a surgical component.
By being a prosthetic discipline with a surgical component who should be better to quarterback it, if the surgical component of that puzzle isn't able to be done by the general dentists in the standard of care set by our periodontists and our oral surgeon friends, then we better let them do it for us or get someone that can help us mentor and do it for themselves over and over again for their patients. Whitecap Institute it's in Heber City Utah. It's about 20 minutes from Park City. Everything we do is live surgery. I like the term tire meets the road. I am so sick of didactic lectures that just hypothecate things and talk about stuff. I want to see it. I want to see it done in real time.
I want to be there in the emotion. I want to help our doctors see that things can go wrong. Things can happen in the middle of your intraoperatively that require to think. Some people that I know and back to your controversy if its okay is, there are some guys that will build a surgical guide by a company. I had one in my office about a year ago from California mentoring with me. He put the surgical guide in and he said “Boy there's very lengthy bone.” I said “You missed the bone.” He said “How could that happen? My surgical guide was made by a computer.” I said “Believe me it happens” He missed the bone. There's distortions in cone beams. There's distortions in the process, but we need to use very good sense.
We need to use technology as much as we possibly can because it's all about the patient and at the end of the day, if technology makes it better then use it. If you can do it without the technology as well as with the technology then do it. At this point I don't think the standard of care on that is then determined. I do have two cone beams in my office. I use them preoperatively every time, and I use them postoperatively every time. I have to tell you I learn so much when I look at something three-dimensionally postoperatively. Those of you who have cone beams out there don't be stingy with them. Take postoperative shots of your endo. Take postoperative shots of your implants.
Howard: That has always wanted me to ask specifically. My whole deal is with Dentaltown. No one is alone. I know out of 7,000 of you if someone saying which cone beam did you get?
PK Clark: Let me say they're all good because when you get one you are going to be so fortunate to be able to see things a two-dimensional shot won't show you. Those of you who don't have the machine for crying out loud, learn how to read the discs. They're so easy right now. It's not an excuse today. I don't have a cone beam to not be able to decipher the information. Specifically to your question Howard, I am a Carestream fan. I’ve got a 9300 and 9000.
Howard: That's what I got. I've got the Carestream.
PK Clark: I've been very happy with Carestream, but they're solid machine and I am not a big computer wizard. What I love about it is I can get the information every time without a big deal.
Howard: These people listening are probably wondering tell us more about like is it one weekend or is it one weekend a month for three months and how much money is it? What is your program? How long? How much, all that.
PK Clark: Thank you. The initial program I am calling implant boot camp. It's a Thursday Friday Saturday. The doctors very easily can get a Utah dental license. It'll take them nine days and a couple of hundred bucks. They can get a Utah license and we will mentor them on Saturday to place their first implant under minute-to-minute second-to-second tutelage. That is the biggest thing that I could say that we do. The live surgery allows them to pull the trigger on this fearful event on a patient that I've chosen. On a patient that I will take further care of. That Thursday and Friday and half day Saturday, they're learning hands-on procedures for treatment planning. I have boiled it down to 13 questions one has to ask and answer to treatment plan appropriately for all the different circumstances out there.
We teach them protocols of implant placement called LAD the White Cap way; location angulation and depth. We talked about incision design. We talk about reflection tips and tricks and suturing tips and tricks. When to do it at one stage, when to do it two stage. When you would absolutely do a two stage. We go over contemporary medical histories that deserve more discernment from a general practitioner rather than the formality of just simply signing a medical history. There are times as an implant doctor you don't take the boat off the dock because their medical risk factors are not conducive for safe flying or safe boating that day.
It's a three-day course. It's 3900 and I don't know, $3950 or something. That includes us placing … They place the implant. At that point are you trained to do that? Some guys are. Let's face it. This is a very long pursuit of acquisition of information and experiences. There are so many good educators out there. The thing that I do better than anybody is I care about my doctors more than anybody. I am a general dentist. I know and feel and live their life and I can help them integrate implantology into their office in a very safe and predictable way and that's so important. Safety is so important.
Predictability is always not just a happenstance thing. What it is it’s predictability comes from protocols, and we will teach protocols on how to do pain control protocols prior to their surgical experience, and afterwards with their patients to be pain-free, but then I mentor with them one-on-one. I mentor about a 75-80 days a year. You rent me and I come. I worked with a wonderful dentist from St. George Utah yesterday. He did his first lateral window sinus lift. Do you think that guy was happy? He was so excited. He placed two immediate implants. We did it with guided surgery Howard. We had a guide and it was surgically or computer driven but we reflected a big flap. He opened the lateral window with a technique that I shared with him.
We put in 3.5 grams of BIOS mixed with high-octane blood. We do all blood draws and use Rh factor acquisition. We are using a PRGF. I've used a LPRF. I've used them all. They all work. They're all wonderful but mentoring is where the absolute growth takes place. I mentored one young doctor from Vernal Utah who rented me over 3-4 years about 16 days. He does 450 implants a year.
Howard: Now are you going to his office or is he going to yours?
PK Clark: He is coming to my office because I've got the cone beam. I've got the big inventory. I've got the blood acquisition stuff. I do the IV sedation with them and for them. I also have an online store that I offer my doctors wholesale cost of prices for all their sutures and biologics and implants and abutments. Then I also have a 5-axis milling company that mills custom bars, all round house zirconia, all under Whitecap names. We have a Whitecap lab. A Whitecap store. A Whitecap institute and a Whitecap dental implant center.
Howard: What is the main website that will get you to all of those?
PK Clark: I don't know. Let’s see …
Howard: Whitecap institute.
PK Clark: White cap institute would drive you to anything you want.
Howard: You said you have two Carestreams. What were the two numbers you gave?
PK Clark: 9000 and 9300.
Howard: 9000 and 9300. I know someone is saying “Well I'm not going to buy two like you. If I was just going to buy one of those two which one would you buy?”
PK Clark: Well actually the 9000 if I understand Carestream’s business plan right is no longer being sold. It’s an 8100. It is a smaller footprint but it’s essentially what the old 9000 was, and they're selling that like hot cakes in the country. As a general practitioner I would buy the I-8100. You can get stitching to stitch and do a full craniofacial scan if you want, but it is absolutely resolution beautiful. It is exposure to radiation is beautiful. The 9300 is more guys that are doing sleep disease; want to see airways, guys that want to see TMJ joints, want to see full bilateral views of sinuses stuff like that.
The 8100, the newest machine replacing the 9000 is probably the thing that most general dentists would want to buy. I think the best buy in the … You know they are probably around I don't know somewhere in the high seventies.
Howard: 70,000 for that. I want to ask you another question I get all the time. The largest dental meeting in the world is every other year in Cologne. It's like a 110,000 dentists show up and it is a 5-day dental unbelievable, but there were 274 different companies selling implants. When you're an individual dentist and she's driving to work right now in her Honda Accord. She's saying “Is titanium titanium? Is there value in buying a $500 implant? Am I not going to get a good one if I only pay 150 for an implant?” How do you help this individual decide out of 274 people all selling titanium, all saying theirs is the best, how do you help form that decision?
PK Clark: That's is a great question and I've presented some world-class first of its type research in the Cologne IDS meeting, the last two meetings. I'm familiar with that huge meeting. It's a wonderful forum and venue, but at the end of the day I think you want to implant they’ve all lost their patents. All of the best of the best of the bells and whistles are boiling to the top, so at this point you're looking for a company that's doing massive amounts of R&D to improve. For example right now the biggest thing in implantology is the nanotechnology on the thread surfaces of the implant body. A lot of implants are mimicking some really good implants and the implant that I use is called Hiossen.
It is an Astra Tech knockoff. Astra Tech was bought recently by DENTSPLY but it's a more shaper power thread platform switching kind of implant with some really good surface …
Howard: You are saying it is an Astra tech knockoff?
PK Clark: Ah-ha (Affirmative).
Howard: It is a Korean company isn’t it?
PK Clark: That's correct.
Howard: CareStream that's your CBCT, that's a Canadian company and isn’t that in Toronto?
PK Clark: It could be, I think so.
Howard: You are saying Hiossen it is not Astra Tech. It is DENTSPLY Astra Tech, it is a knockoff but its South Korean.
PK Clark: Yeah and it's affordable. Your Astra tech is really good for your specialists that don’t have the overhead we generalists have, but I can tell you that Hiossen is a subsidiary of Osstem and Osstem is the parent company. They sell the most implants in volume of anybody on the planet earth today.
Howard: Spell Osstem.
PK Clark: A-O-S-T … – O-S-T …
Howard: E-U-M?
PK Clark: I-U-M?
Howard: I-U-M? That's the parent company that owns Hiossen?
PK Clark: Yeah.
Howard: You say unit wise they sell the most implants?
PK Clark: Per volume Osstem is selling the most per volume. It used to be Straumann and then it was Nobel. Nobel recently was bought by …
Howard: By Danaher.
PK Clark: Danaher yeah.
Howard: Don’t do those implants direct.
PK Clark: Yeah they don’t implant direct and all the [Cabulker 00:29:27] companies but they are a bit merger and acquisition company in the US, and they just bought that. I think they bought it for the Chinese market to be honest that's my take.
Howard: Danaher bought Nobel Biocare for the Chinese market?
PK Clark: Absolutely.
Howard: Explain that.
PK Clark: It's hard to get into China as you might know and once you're in, then it's easier to just buy the companies that are already in than it is to try to force your way in because the companies that are already in are closing the doors and saying to the Chinese “You don’t need anybody more. Just keep them all out of your boundaries” and so it's a turf battle, so acquisitions of big companies are being done for those kind of strategic reasons. Back to your question, there's a lot of good implants out there. To me the surgical kit is one of the most important and it's overlooked. You need an implant system. My surgical choice is Hiossen and I'm a privateer here. I sell Hiossen in my private store cheaper than anybody can get it through the other stores because I'm doing it for my doctor friends.
I want them to get the best value they possibly can but it's a knockoff of Astra Tech. It's a platform switching. It is Morse taper. It's a powered thread. It's got all of the surface ingredients you need and it's priced equivalent to an implant direct.
Howard: I think Gordon is coming to my backyard this October giving a one day lecture on Hiossen.
PK Clark: Yeah he's into the one piece Hiossen's for sure Gordon is [crosstalk 00:31:07] for me.
Howard: Can you believe that guy is eighty years old?
PK Clark: I was at his place some time ago and I couldn't keep up with him. I just didn’t know so much. He's just got all …
Howard: I am 52 and I can't keep up with him and he's 80. I'll tell you what. That guy is amazing. You would recommend Hiossen basically?
PK Clark: I would recommend an implant system that's going to be around in 10 years that's doing R&D, that has a very great surgical kit. The Hiossen surgical kit ahs depth stops for every length. I do 5-10 implants a day some weeks and I'll tell you, as many implants as I've done Howard I still appreciate the depth stop. It's fixed to the burr. It’s not movable and then I can use my energy to focus on all the other things that make that implant outcome so vitally important for my patient. I do love a depth stop. I think it's super safe. If I have to incrementally go closer to an anatomical structure with huge risk value, I go ahead and use that depth stop to treat close, close, close without inadvertently getting where I don't want to be.
It's so important that we do more implants for less. I think the implants are too much from a doctor standpoint. We're charging too much. We've got to lessen the fee. We got to do more for more ordinary people, school teachers …
Howard: And you sell more. Every time you lower the price, you sell more. The largest companies in America always go lowest scores. In dental labs it was Glidewell. They’ve got 5% of the market. In airlines it was Southwest; in distribution it was Wal-Mart, it was Costco. The only secret to lower prices is lower cost. My dad told me that God gave two eyes and I was supposed to keep one eye on the customer and one eye on costs. He said God gave you a little brain and all you are supposed to do is drive down costs so your customers have the freedom to afford to buy what you buy. What dentists always do is they always go to these institutes that want to make a mountain out of a molehill.
If you go to a study club they just show off like I trim my own [dyes 00:33:15], I crave my own stone then trim my own dyes. This was like I have my own beehive to grow my own wax and then carve my own stone and then I trim my own dyes and it takes me 40 days and 40 nights to make one crown and I sell it to a king for 10,000. That's not America. That's not the America I know. Henry Ford said it's not technology until it's supplied to the masses. I want to ask you another controversial part of this article. I said that from ‘87 to now what I am, the 28 years I've been a dentist that we keep going out into a field and building this wooden barn and then after we build it we tell the patient to brush it and floss it and use a tongue scraper and Listerine and then six and half years later the termites go get the barn and then we blame it all on the patient.
Now with implants we have a chance to go in there and make a titanium barn so that when the termites come back, the Streptococcus mutans, they can’t eat it. Some people say okay titanium can’t get a cavity but it still getting the periodontals easily, periimplantitis but I have to tell you that … I'm a diplomat in the International Congress of Implantology. I have my fellowship in this institute. I don't think P gingivalis goes to titanium like it does that nasty periodontally infected tooth or the cementum is all gritty. I don’t think you can just say you take out a periodontally involved tooth and you suck out the bugs in the mouth and it’s going to get periimplantitis. Do you agree or disagree with that statement?
PK Clark: I am an observational learner. If you want the histology and all of that you're talking to the wrong guy, but what I do know is I've lived with my implant results now for twenty five-plus years. I’ve seen the really good. I've seen some bad and ugly and I've participated in it. I'm not exonerating myself from any of that responsibility. At the end of the day thank goodness the periodontal disease that is rampantly affecting massive amounts of people in the world does not affect the implant from my observational learning at all. This periimplantitis I think the fuse to it is bad dentistry, bad margins of the abutments to the crowns.
It's certainly a seepage of excess cement with ill regard for that. It is a blatant disregard for biologic width and at the end of the day that is why periimplantitis in my opinion is taking some people's implants to the cleaners and ravaging the bone and exposing threads and having chronic irritational issues. It didn't start because of bacteria. Bacteria is invading those sites that were propagated by improper margins, cements, contours of crowns and disregard for biologic width.
Now do I believe for a second that we can get biologic width likely with sharpey fibers around a tooth that’s measured like 1.8 or 2.4 depending on what dental school you went to? No; however, we can mimic it through hemidesmosomal attachments to a fresh, clean titanium or hybrid abutment of zirconia and titanium, but at the end of the day everybody is building out their popsicles on sticks. The stick is the implant, a little hole over that is a tissue former and on one stage is propagating popsicles on a stick.
It's ridiculous. We're not doing emergence profiling the way we should and in my opinion what you do to overcome that is you go to good educational clinicians that do it all the time, not just somebody sponsored by a company for a bunch of money and you learn how to do it for people you love and those are your patients. I think we need to mimic biologic width by putting an implant abutment in a bloody hole. A bloody hole allows that fresh blood on a sterilized abutment to form a hemidesmosomal attachment never to be undone again if it's done right and the screw doesn’t loosen or break or some other sequelae, but at the end of the day no one is talking about it. Biohorizon is doing some really cool things with laser lock kind of technology. We're starting to hedge that way but we as generalists have to demand a mimicry of the biologic width on our patients’ surgical outcomes and prosthetic solutions on the implants.
They'll be long lasting. The tissue will be stable. If tissue is stable the bone will be stable, if the occlusion is correct and that's how I feel.
Howard: Okay PK I want to slow it down a little bit because you and I are fifty and I've done this for twenty years and how many years you’ve been doing this now?
PK Clark: Since ’89.
Howard: 26 sometimes we forget how much we slowly learned along the way and accumulated but I know there's going to be out of 7000 dentists there's going to be at least 500 that don't really get the biological minimal width. You are talking elite. Will you just slow down a little bit and explain what the biological minimum width is to people who are just entering their career?
PK Clark: I think biological width is a fundamental principle. Well let's go back here. If we want to put it into a histologic terms, let me ask you Howard where in our body is our epithelium perforated? I am not trying to be a smart-aleck but …
Howard: Gum tissue, sinuses.
PK Clark: Gum tissues. if I take my epithelial finger and put it in my epithelial nose and through the epithelial track and out the end it's all epithelium. Same in the ear, same in the eyes. Same everywhere except where the tooth penetrates the bone. Our creator made it possible for that. That's why the cementum of a tooth is at the position it is at because just above the bone, the sharpey fivers of the connective tissue shoot themselves into the tooth forming a biologic seal keeping blood in and germs out. With that said, the biologic width is simply a barrier of space. Some schools say its 1.8 millimeters; some say it’s 2.2. I don't think it really matters but the fact of the matter is it is there. If a general dentist penetrates or violates the biological width in any way you get chronic irritation.
We do that by not doing crown lengthening appropriately and we put crowns with margins way below encroaching or in the biologic width. Biologic width is a protective mechanism to protect our body from bacteria, so when we put a dental implant fixture in bone, it’s going to osseo-immigrate and it's going to become one with the bone. However, when we put the connection or the abutment into the implant at that point we have to be very, very savvy with our thinking. In the olden days when you and I started doing implants Howard that margin was right at the top of the implant which was at the top of the bone, which then left us no option and we cemented them in there.
We knew no better, no one was telling us any differently but today any savvy clinical prosthetic implant person’s going to put the margin just below the gum so they can readily clean it up if they're not doing screw retained to begin with, allowing for an unencumbered clean surface to become biologically somehow connected to that issue which I am going to call a mimic; a mimic of the biologic width which is only happening if you have fresh blood when you put your final abutment in. I'm going to ask the audience and here's my question to you. Have you ever taken a tissue former out and seen it bleed? Absolutely we all have.
When you saw that did you think that it was inflammation as I did? Yeah it wasn't. That abutment went into the surgical site with fresh blood and that titanium abutment at that time maybe it's just a tissue former or a healing abutment. They are all the same when in hemidesmosomal attachments created a seal and when we inadvertently took it out, we got blood. Then we put our transfer abutment in and took a final impression. Then we put it back in and then we took it out again, when we put our prosthesis in and we're going to be so clever we don't numb the patient up, so then we put the final abutment in.
We never have blood again. We put and cement it because we didn't numb them, we don't want to hurt them so therefore we don't clean it the way we should and we got a big fat mess. At the end of the day biologic width is very important but you got to have fresh blood and a sterile abutment. How many of you doctors wipe down your abutments with alcohol before you put them in a human? Guess what? Your lab teach was either smoking crack at lunch or a tuna fish sandwich with mayonnaise on it. Nonetheless there’s oils from their hands. It's touching that abutment. You’ve got to think outside the box get that abutment clean, get it sterilized, numb the patients up, get the rete pegs opened up and ready to do something that they've been trained to do.
There's not a tooth there but to adapt itself to whatever the doctor finally puts in there, clean and void of cement. That's the biologic width and its [crosstalk 00:43:03] version.
Howard: Answer that question because should you screw our cement because if you don't clean the cement, that's a large problem.
PK Clark: Big problem.
Howard: If you’ve placed a hundred singles, what percent would you screw versus cement?
PK Clark: What year? I did a lot of cement retained and I thought I was doing it really, really well and I come to find out that I didn't do it as well as I thought because I've had periimplantitis not caused by bacteria but by cement that I left. I reflect a flap, boom, right there. The cement’s there. I have a dear friend in Portland Oregon, oral surgeon and he has about 120 referring doctors. His biggest nightmare is cement. He will reflect a flap several times a week just removing cement. If you are the purist, which we should be if you love your patient and you wanted to be the very best when you've mastered all of the little things I would say and you only can live in one camp or another, which isn’t a fair proposition but let's just say you can only live in one camp for the rest of your life and it would be a screw retained prosthesis for sure.
Howard: I want to say first of all that I have a lot of dentist friends in Utah and they all think you're a legend, I mean they all. I was talking to one this morning and he told it will be my best podcast ever. I said I've done 130 and he goes it will be your best. I want to keep getting your amazing mind on controversial stuff. This is a huge controversy. You come from a big family of six kids. I have four kids. I grew up with five sisters and a brother a mom that stayed home and a dad that delivered rainbow bread. We were so poor we didn't even know we were poor okay. It seems like if you ever have one of the 30 million people that wear a denture, most of them are a grandma and if you send them to a dentist, a prosthetist or oral surgeon, they only present a Mercedes-Benz a $50,000 All-on-4 some big implant.
It is always fifty grand so then I think about 90% of America including a lot of dentists listening to this podcast don't have 50 grand. Then they just go home and they are nothing. If you suggest on Dentaltown well maybe you could just go like or 4 minis and 3M bought Imtec, 4 implants on the bottom and 6 implants on the upper maybe instead of just $50,000 treatment you got a $5000 treatment. I swear on Dentaltown we had two separate in implantology root forms from minis because anybody that posts a mini case it's just going to get dived on saying “Oh no you can’t do that. You can’t do that. You can’t do that.” I want to say this. Do you believe in market segmentation? Do you believe there's such thing as a Chevy and a little more money, a Pontiac, a little more money, a Buick, little bit more money, a Cadillac or is it just one Mercedes-Benz fits all?
PK Clark: I don’t believe in that at all. I believe in educating your patient to understand what their options are and I can take a poor patient and I say poor I mean somebody that can barely, they are living on fixed income and you can rebase their old denture. You can place two implants in a proper position in the mandible and you can give them a locator and O-ring or maybe a stud abutment and O-ring abutment with a [Dale bow 00:46:35] or maybe even do a Hader bar with distal extended ERAs depending on the budget. I believe the minimum on the lower is two. I believe the minimum on the upper is 4. I don't think the diameter of the implant really matters. The hard costs are so close together if they've got bone for a two-piece implant use a two-piece implant.
If they don't have any bone and you have to put a 1.8 or 2.2 or 2.8 diameter one piece, do it but when tooth go away, bone goes away. When an implant is put back in it totally changes the dynamics of that bone and it saves that patient, but I also believe that some of these patients need to have a little more surgery maybe chop up the bone because it's knife edged, but my biggest gratification in life is helping people that can’t eat, can’t go out socially. I can do an upper lower case for 10,000-12,000 bucks.
Howard: Really?
PK Clark: Oh absolutely.
Howard: Is that removable or fixed?
PK Clark: Removable. Here's the thing I've also learned. Don't give somebody that doesn't have a budget a fixed solution that is going to cost a boatload of money to service in the future. Do it right, give them a removable solution. The problem is if I bite down with a denture and I might be wrong on this, but I'm just talking metaphorically about 25 pounds per square inch is all an identified patient can bite down on their teeth with plates You give them a couple of implants you are up into the 200 pound per square inch or something like that. It’s quantum leaps. Our older patients deserve it and when we first got out of dental school, everybody was so excited about [Brandon Mark 00:48:20] it was 50,000 bucks and 25,000 to train and these poor people just gave up on it, but we have an obligation to help our patients.
When bone goes away it goes away up and in or down and in, and we have an obligation to support the orbicularis oris. We have an obligation to give them back physics to masticate their food. These poor people aren't just suffering from ill fitting dentures. Their whole life was debilitated. Their phonetics are struggling. Their face is caving in. Their vertical dimension has collapsed and they are embarrassed and they are humiliated as you know life takes things away from you as you get older. I think it's a great privilege and an honor to help people like that and so doctors that have the $50,000 case and that's all they do, shame on them.
They need to get a little bit of a grip that their talents they have obtained are there to help other people and you got to have a diverse treatment portfolio and a diverse treatment acumen of skill sets to meet these people's needs and do it for heaven's sakes not for the almighty dollar, but to just help humanity and feel good at the end of the day you did a good job. Will you make money? Heck yeah. You're going to make money don't worry about that. You just need to feel good by making money and a lot of guys in our profession make a lot of money, but I don't know how they feel good because I've seen some of their work. We need to step it up. We need to be the very best. We need to be the kind of dentists our mothers think we are.
Howard: I love that. I had a lady today that had been tearing up too because she couldn't wear a denture at night. The thought of taking out in front of her husband it couldn’t happen, so she lied to him and told him that he snores, rolls, kicks, you can’t sleep in her room. She got a lock on her door and then he had to sleep on the couch and then a year later he left. She said I lost my husband because I never addressed my teeth. I just thought that was so sad. She lost the love of her life. Henry Ford you know when he made his first model T it was $668. Ten million units late it was down to $228. He squeezed two-thirds down on the price and that's why he's a legend. You are just amazing, amazing, amazing.
I wish you would, I know it's counterintuitive but if you put a course up on Dentaltown we have a … I am thinking of PK’s truisms or I love the title what's good for the tooth is not good for the implant. I love all this stuff, but we put up 300 and now I think 25 courses and they just passed 550,000 views. I think if you put up online … They are now our savings. You do one hour, two hours, ten hours whatever I think it will do a lot of good and drive a hell of a lot of people to your center because I really want your message to get out more. I think everybody should hear it. I want you to address this question. A lot of people say the problem with the implants is that the person who never took care of their tooth, or they smoke.
They had gum disease. They had cavities I mean it's kind of a lot of people are saying you know there's a reason these people are missing a tooth and it is because they smoke and they are obese and they're alcoholics and they got cavities. They don’t take care of everything and a lot of them think they're not even an indication for an implant because for all the reasons they lost a tooth is why they shouldn't get an implant in the crown. What would you say to that young dentist?
PK Clark: I would say to the young dentist that at first glance they might feel that they’re right but as they grow and experience life they will come to know that people change; their priorities change. They grow up and just simply because they did not appreciate what God gave them originally they beat it up. They neglected it. They abused it and lost it, do we put them in a penalty box for the rest of their life? I say no. I say that they come to appreciate something they’ve lost after its lost. I know that's true for me. I know that's true for people I know and therefore I have to know and I've heard it so many times these patients are rebooted. They want a quality of life and I think it's our obligation to for sure address the issue
For sure reboot them into proper maintenance and care of their oral cavity and health. I think that we need to give them credit and not put them in a penalty box for the rest of their lives simply because they're smokers; simply because they abuse the teeth, who are we to make that judgment. I think it's our obligation to treat everybody as well as we possibly can, let the patient decide what they want drive. Drive opportunities or options their way and I can tell you that patients that have had rehabilitation whether it be Mercedes or the red wagon, they love it and they're appreciative of it and they usually take pretty good care of it.
Howard: I want you to go back to something you earlier said that went over a lot of people's heads, you started your own lab, your own dental lab and all those things you are talking about, describe treatment planning and why you started your lab and what lab services you offer because you said okay low-budget two implants O-rings. Then you said Hader bar. The Hader bar, Dolder bar, no one knows the difference between those two. Explain the 80-20 rule. What is 80% of the things your lab is making? I assume it's all for implant removable or is it also implant fixed?
PK Clark: Both. The reason I built the lab is we were doing a bunch of not always just offered the Mercedes but we do a Mercedes and the lab bills were so astronomical they were inhibiting me from offering it to the public and so we were doing about 4 or 5 full mouth cases a month and were trying to do all sorts of elaborate solutions. I bought a 5-axis milling machine from Frankfurt, Germany. It is called the Datron 5, a dental 5, 5-axis with an I-metric white light scanner five years ago. I had the first in the country of this type and I just put it in my dental office and I hired at CAD/CAM tech and we just grew. Today we offered our business the first of this year and we have ninety doctors that use us. We do bars. We do custom titanium abutments, custom titanium zirconia abutments.
I have to tell the young doctor I'm not a big fan of old zirconia abutments. Beware of them. I think they will break. I like a titanium base end of the implant and then a zirconia on top of that and then an Emax on top of that, but I think I built the lab for me. I now have two milling machines, 12 employees just roving to help our doctors we train. Whitecap Institute we train you, we help you buy wholesale pricing for all of your parts and pieces and then we fabricate what others refuse to fabricate for a reasonable fee. I will do bars on 4 implants for a thousand bucks. Other people are charging a lot more.
Howard: Now a surgical guide is pretty much, if you’ve got a tooth in front behind but on both sides you might be able to eyeball that have a CBCT and make sure it is nothing, but when you are trying to parallel two implants or three or four, then you really got to have it correct?
PK Clark: I would ask if it's imperative that everything's perfectly parallel? The physics would say it might be better if they were offset just a squash to be more fundamentally a foundation, but no I think where you need a surgical guide absolutely imperative you have a surgical guide is when you have no reference points. The typical no reference point game is when there's no goal post. There's no nothing. It is the edentulous ridges upper and lower. You reflect a flap you may have known where midline was prior to your reflection, but after the flap is reflected you lose where that was.
Howard: How are you making a surgical guide? Is your lab making them or you taking an alginate and making them on a model?
PK Clark: It is old school alginate on models. We send them out and outsource them to companies like Anatomage or 360 or the company in Reno I forgot. They would be disappointed I don't remember their name but anyway there's companies out there that can build surgical guides but at end of the day you can't expect to freehand implants as well as you can prefabricating something to allow you to be better at hitting the bone, where you want it. It's a prosthetic game so you’ve got to place the implants where the prosthesis need them. When the prosthesis needs an implant you got to grow bones. Sometimes you got to augment, sometimes you got to ridge slits. Sometimes you've got to do clever things because it's not necessarily the number of implants. It is the strategic position of the implants that's probably the most important. I'm not a big All-on-4 guy. I like All-on-5 or 6 or more but it's all good as long as the price is fair to the patient.
Howard: Does an implant company own All-on-4 or they just have a contract to sell the implants to them?
PK Clark: No I think Nobel doesn't own it but they’ve certainly adopted it and used it to the maximum way they possibly could. I think as you go to international and national symposiums the All-on-4 concept is being replaced by All-on-5 or 6. The concept of taking a patient to the operating room, doing all of the surgery and leaving with the prosthesis in their head is a wonderful thing for the human that receives it.
Howard: What I love about the All-on-4 or is the millions of dollars of advertising they do each year and I've had more little old ladies come in with just like a piece of paper or something out of the newspaper, a magazine and dentists don't realize that when other companies advertise they are your patients too and if they love and trust and respect you their advertising is making them come to you and asking questions. I really wish you would do some of the online courses. I wish you would do on the practice management of how to do the fees. I know you're an expert in that. I wish you would do the lab work because on what your lab makes for treatment planning on a fully edentulous, I would give anything because these people are watching these like say we just passed 200,000 members on Dentaltown.
We just passed 35,000 have downloaded the app so they're watching these courses on their iPhones or iPads or computers. I think the old guys like Brand Mark and Mish they built up reputation because they were doing a dog-and-pony show in a physical brick building every week in their whole life till they … almost Brand Mark’s gone and Carl Mish I hope he's doing well but guys the internet there's two million dentists out there and we are connected now. I mean you could give a course and they could be watching it in Katmandu while you are sleep. We're out of time. It's been an hour and one minute but I want to tell you … Oh last question as everybody wondering. When we got our school, you taught in Nova Dental School. Do they have one now or do they have two?
PK Clark: They have two. Rosemont and University of Utah.
Howard: University of Utah is in Provo?
PK Clark: No Salt lake.
Howard: Oh University of Utah is in Salt Lake. BYU is in Provo.
PK Clark: BYU is in Provo.
Howard: Where is the other one? Rosemont where’s that?
PK Clark: Its in Salt Lake valley somewhere. I've never been there but they take eighty students a year. University of Utah is taking 20 so essentially Utah went from nothing to 80 seats in dental school a year in the last couple of years.
Howard: Do you think that was a good thing or unnecessary?
PK Clark: You know it is what it is. I think it's nice for Utah guys to not leave and spend all the money they would spend to go wherever. I think Utah has too many dentists. No one's going to argue that. I think the inner mountain has too many dentists, but wherever you get your training you make it the very best dental school and just go and do your thing in a community where you want to live.
Howard: Do you ever go to Southern Utah, South Utah because that's where Phoenix is. I think every third person I know was born in Utah. They’d call it phoenix/Utah. I am out of time. It is an hour and one. Do you think you might make some online courses?
PK Clark: Of course I’ll do it.
Howard: Really I would just oh my god you're an idol, you're a legend. I hear nothing but good things about you. Thank you so much for spending an hour with me today and I hope to see online courses from you in the future.
PK Clark: Thank you.
Howard: I got a new associate, a young one and I want to send him to your deal. You’ll probably be seeing him. I can’t go to your course because I don't have enough discipline. I would start skiing in Park City. I don't know if I have the discipline. I’ll probably sneak out the back door. I love snow skiing and that place is, it's probably the best ski resort there is.
PK Clark: I think Utah and Colorado probably rock the USA.
Howard: Utah is better than Colorado. I've skied there a lot and the Utah has just got bigger mountains, less crowds, ski to the lift. Sometimes you go to Breckenridge and things like all you remember is waiting in the lift line.
PK Clark: True.
Howard: Thank you for all that you do PK. Thank you very much.
PK Clark: All right bye-bye.